Snapshot A 42-year-old female is rescued from a burning building by firefighters and brought to the hospital. On examination, her pulse is 100/min, blood pressure is 130/60 mmHg, respirations are 34/min, and weight is 60 kg (132 lbs). She has second and third degree burns over her anterior and posterior chest and abdomen, bilateral arms and hands, and second degree burns over her face. She is coughing, spitting out carbonaceous sputum, has singed eyebrows and vibrissae (nostril hair) and a hoarse voice. Because of signs for inhalational burns, she is first intubated and ventilated. Total body surface area (BSA) involved is estimated to be 58.5%. She is given 100% oxygen, and IV lactated Ringer's (58.5% BSA x 60kg x 4ml = 14,040 ml) with 7 L administered in the first 8 hours of admission, and another 7 L in the next 16 hours. She is transferred emergently to a burn center because of facial and inhalational burns. Introduction Fourth leading cause of death in children Types of burns include chemical (acid/alkali), electrical, radiation (UV, medical/therapeutic), thermal (scald, fire) can be seasonal (e.g., fireworks) can be associated with abuse Most common causes children: scald burns adults: flame burns Pathophysiology three zones (from outermost to innermost): hyperemia, edema, ischemia zone of hyperemia vasodilation from inflammation viable tissue (recovery within 7 days) zone of stasis/edema decreased perfusion with microvascular thrombosis progressive tissue necrosis (death in 1-2 days without treatment) zone where early treatment has most benefit zone of ischemia no blood flow irreversible damage Presentation Classification (New)Degree(Traditional)SiteSymptoms/SignsErythema/Superficial1st degreeEpidermis+ PainBlanchableSuperficial-partial thickness2nd degreeInto superficial dermis+ PainBlanchableBlistersDeep-partial thickness3rd degreeInto deep dermis- PainNOT blanchableSoftFull thickness4th degreeInto underlying muscle/bone- PainNOT blanchableHard Evaluation Primary and secondary survey brush off gross contaminate and remove all clothing if chemical burn, best next step: irrigation alkali burns penetrate more deeply / rapidly than acid burns Prognosis based on patient age, burn size, and evidence of inhalational injury obvious skin wounds evaluate locations of burns estimate involvedbody surface area (% BSA) each "hand width" area burned is 1% BSA use Rule of 9's for adults (see above) use Lund-Browder chart for children < 10 years this is only for superficial and deep thickness burns (2nd/3rd degree) NOT for erythemas (1st degree) with electrical burns, deep tissue destruction may not be visible suggestions of inhalational injury facial burns and singed nasal hairs hoarseness, stridor, dyspnea altered mental status, headache, coma cherry red skin is NOT reliable (late, post-mortem finding) Investigations arterial blood gas and carboxyhemoglobin level CBC / electrolytes / urinalysis chest radiograph electrocardiogram Management Special considerations in ABC resuscitation if inhalational injury is suspected, best next step: immediate intubation impending airway edema best diagnostic test: bronchoscopy CXR or ABG cannot rule out inhalational injury if CO poisoning is suspected, best next step: 100% O2 by facemask until carboxyhemoglobin level < 10% if burn eschar encircles chest, best next step: escharotomy to relieve constriction Restoration of normal skin function: thermoregulation, fluid control, and infection prevention thermoregulation increase room temperature, cover patient with blankets, and use warmed fluids fluid control use Parkland formula as baseline 4 ml of Lactated Ringer's per kilogram per % BSA over first 24 hours first half given over first 8 hours second half given over next 16 hours additional fluid required if electrical burn, inhalational injury, BSA > 80%, resuscitation delayed, or 4th degree burns are present monitoring clear mental status vitals mean arterial pressure > 70 mmHg pulse < 120/min urine output children (< 12 years): > 1.0 ml/kg/hr adults: > 0.5 ml/kg/hr infection prevention tetanus prophylaxis all patients with > 10% BSA burn or burn worse than superficial thickness need Td cleanse and cover with dry sterile dressing mafenide acetate a topical antibiotic with broad spectrum coverage can penetrate thick eschar topical silver sulfadiazine do NOT use in pregnant patients, children < 2 months old do NOT use around eyes NO benefit in prophylactic PO/IV antibiotics or corticosteroids Burn surgery debridement to level of bleeding capillaries apply split thickness skin grafts over excised areas escharotomy for circumferential burns Other considerations stress ulcer prophylaxis H2 antagonists or proton pump inhibitors nutrition prepare additional supplements/tube feeds basal metabolic rate increases by 2x - 3x if BSA% > 40% Criteria for transfer to burn center full thickness burn > 5% BSA full or partial thickness burn over critical areas (face, hands, feet, genitals, perineum, major joints) circumferential burns chemical, electrical or lightning injury electrical burns may have cardiac arrythmia or ventricular fibrillation, unexpected falls with fractures and dislocations inhalational injury preexisting medical problems special psychosocial or rehabilitative care needs